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24
<br /> 11111111111 IN 111111111
<br /> 1. Print name of Person 5 7. What is this person's race?
<br /> First Name MI Mark XX one or more boxes AND print origins.
<br /> ❑ ❑ White-Print,for example,German,Irish,English,Italian,
<br /> Lebanese,Egyptian,etc.7
<br /> Last Name(s)
<br /> Black or African Am.-Print,for example,African American,
<br /> 2. Does this person usually live or stay somewhere else? Jamaican,Haitian, Nigerian,Ethiopian,Somali,etc.7
<br /> Mark❑X all that apply. i F — -
<br /> n No
<br /> American Indian or Alaska Native-Print name of enrolled or
<br /> Yes,for college f„j Yes,with a parent or principal tribe(s),for example,Navajo Nation,Blackfeet Tribe,
<br /> other relative Mayan,Aztec,Native Village of Barrow Inupiat Traditional
<br /> U Yes,for a military assignment ❑ Yes, at a seasonal or
<br /> Government,Nome Eskimo Community,etc.
<br /> second residence -
<br /> ❑ Yes,for a job or business ❑ Yes, in a jail or prison
<br /> Cl Yes, in a nursing home ❑ Yes,for another reason v
<br /> ❑ Chinese ❑ Vietn s Native Hawaiian
<br /> 3. How is this person related to Person 1?Mark X❑ONEbox ❑ Filipino ❑ n Samoan
<br /> U Opposite-sex husband/wife/spouse U Father or mother
<br /> ❑ Asian Indian Ja se ❑ Chamorro
<br /> Cl Opposite-sex unmarried partner ❑ Grandchild _
<br /> ❑ Other i ❑ Other Pacific Islander-
<br /> ❑ Same-sex husband/wife/spouse Pr' to x Print,for example,
<br /> ❑ Parent-in-law sdian, Tongan, Fijian,
<br /> g, Marshallese,etc.7
<br /> El Same-sexunmarried partner ❑ Son-in-law or daughter-in-law
<br /> ❑ Biological son or daughter ❑ Other relative FTI
<br /> ❑ Adopted son or daughter ❑ Roommate or house
<br /> Some other race-Print race or origin.�
<br /> ❑ Stepson or stepdaughter ❑ Foster child
<br /> ❑ Brother or sister ❑ Other r ive - - -
<br /> 4. What is this person's sex?Mark X
<br /> i Male ! Female O
<br /> 5. What is this person's h t s this person's date of
<br /> birth?For babies/ hen 11y a old,do not write the age in
<br /> months. Write 0 s
<br /> Print numbers in boxes.
<br /> Age on i Month Day Year of birth
<br /> ears
<br /> L --�
<br /> -+ NOTE: Please answer BOTH Question 6 about Hispanic
<br /> origin and Question 7 about race.For this census,Hispanic
<br /> origins are not races.
<br /> 6. Is this person of Hispanic,Latino,or Spanish origin?
<br /> LJ No,not of Hispanic,Latino,or Spanish origin
<br /> ❑ Yes,Mexican,Mexican Am.,Chicano
<br /> ❑ Yes,Puerto Rican
<br /> ❑ Yes,Cuban
<br /> ❑ Yes,another Hispanic,Latino,or Spanish origin-Print,for
<br /> example,Salvadoran,Dominican,Colombian, Guatemalan,
<br /> Spaniard,Ecuadorian,etc. 4 If more people were counted in Question 1 on
<br /> the front page,continue with Person 6 on the
<br /> next page.
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